Changes have been made to the order for audio monitoring at doctor’s appointments

The Moscow Department of Health has amended order No. 1241 on audio monitoring of outpatient doctor appointments in medical institutions. To ensure the anonymity and security of audio recordings, the order clarified that the recordings will be stored for no more than one month, separately from the electronic medical record, without reference to the appointment data and personal data of the patient and doctor. The medical organization will be responsible for compliance with the medical confidentiality regime. The department also analyzed an array of audio recordings of appointments obtained during the “pilot” use of the technology in two city clinics, identified errors made by doctors and came to the conclusion that the recording can improve the quality of their work.

In the fall of 2023, the Moscow Health Department, as part of a pilot project, began audio recording conversations between doctors and patients in order to monitor the correctness of such dialogues. The Department of Health explained that they receive not only complaints from citizens about the “formal, not always respectful” attitude of doctors, but also complaints from doctors about disrespectful behavior on the part of patients. For more than two years, the medical community, together with the patient community, developed rules of mutual respect.

As a result, special recommendations were developed and approved by Order No. 1241. They, for example, suggest “asking the patient questions in a form that is understandable to him,” “if necessary, clarifying what was said,” and “informing the patient of the importance of carrying out the full scope of diagnostic, treatment and rehabilitation measures.” The proposal to audio-record the appointment in order to monitor these recommendations caused a heated discussion. Critics of the order pointed to the risks of violating medical confidentiality and data leaks.

The Department of Health reported that they “carefully analyzed all the opinions of experts, representatives of the medical and patient communities” and made changes in the order to guarantee the anonymity and security of audio recordings. Clause 3.2. the need to submit monthly work schedules for doctors performing outpatient visits with audio recording to the directorate for coordinating the activities of medical organizations of the DMZ has been excluded from the new version of the order. But a provision has been added that all anonymized records will be stored separately from the electronic medical record, in different storage facilities without reference to the appointment data, personal data of the patient and the doctor. The maximum storage period for audio recordings is also indicated – one month. The new version of the order also clarifies that for violation of storage rules, including those that led to the leakage of any audio recording data, and the procedure for working with audio recordings, a medical organization bears responsibility under the law.

The Moscow Department of Health provided Kommersant with the results of a pilot audio monitoring project, which took place from October 23 to November 29, 2023 in city clinics No. 2 and No. 109. Analyzing the records, auditors identified typical errors relating to both the procedure (“composition”) of the reception and its content (“value behavior”). 81.7% of records did not contain the “completion of appointment” block, in which the doctor makes sure that the patient understands the instructions and recommendations; 55% of records could not identify the patient’s examination. In terms of content, the most frequently missing items were the anamnesis collection section (85%), instructions during the examination (64.2%), comments on actions for the patient’s comfort during the examination (70.6%), clarification of the meaning of tests and prescriptions (73.4 %), a block for scheduling a repeat appearance or describing the conditions under which it will be needed” (69.5%), as well as a block for “recommendations on lifestyle and prevention (81.4%).

According to the organizers of the pilot, these errors indicate an insufficient level of adherence to the principles of values: professionalism, patient-centeredness, respect, trust, goodwill and teamwork.

Machine analytics of records of 45,996 techniques performed with errors showed that the top 3 errors included

• non-compliance with communication ethics (65.2%),
• refusal to help (24.2%)
• and offering paid services (5.8%).

At the same time, a comparison of the “starting cut” on October 23 and the “control cut” on November 29 showed that “compliance with the structure of the appointment” has significantly improved: the number of appointments rated “bad” decreased by more than four times (from 1230 to 289), and those rated “good” “, on the contrary, increased ninefold (from 23 to 216). The average assessment of doctors’ “value behavior” during an appointment increased from 8.2 to 9.1 (by 11%).

“It’s no secret that there are cases when patients are dissatisfied with the results of a doctor’s appointment – the doctor was rude, did not explain the prescription, did not explain the subtleties of the diagnosis or did not fully listen to complaints, was indifferent, and so on,” says the head physician of clinic No. 2 Natalya Shindryaeva.—According to the results of the pilot, which was conducted in our clinic, we noticed that patients began to receive more information about their diagnosis and their health. And if there is trust, the patient more carefully follows the recommendations and adheres to treatment. As for the doctors, I would say that they have become more collected, attentive and friendly. Audio monitoring, which is impersonal and not tied to a specific patient, allows you to selectively evaluate and give recommendations to doctors on the tactics of conducting an appointment. Unfortunately, patients can behave differently, and sometimes inappropriate behavior towards doctors occurs. The new project will help minimize such cases, protecting doctors as well.”

“In my opinion, there is nothing bad for doctors, and certainly not for patients, in audio monitoring,” says Anna Efimova, head physician of clinic No. 109. “Independent audio monitoring is an opportunity to improve our work. Agree, no one will be pleased if the doctor communicates in an imperative tone, does not explain anything, and at the end of the appointment says “you are free.” The patient will develop a negative attitude not just towards one specific specialist, but towards the entire clinic, towards the entire healthcare system. The new approach is not needed to punish anyone. If we see that any problem is systemic in nature, we will be able to support specialists, adjust their work or provide additional training. Already during the pilot, we saw a decrease in the number of patients who, after an appointment, go for clarification to the head of departments or other specialists.”

The chief freelance specialist of the Department of Health for primary health care for the adult population, the chief physician of clinic No. 220, Andrei Tyazhelnikov, said that the heads and chief doctors of the clinics themselves asked the department to conduct selective monitoring, since, despite the rules of communication developed within medical organizations, they continue to receive complaints from patients and employees regarding inappropriate behavior of visitors.

“As the chief physician, it is important for me to see the real picture of what is happening in my branches, in doctors’ offices. To understand what problems exist, and how best to solve them with my team,” said Mr. Tyazhelnikov. “We do not give any third parties access to these records. We evaluate them selectively within the clinic. Moreover, these records themselves do not contain information about what kind of patient was seen and which doctor.” In his opinion, “many people find it unpleasant to realize” that their work is becoming transparent, but such control will also protect doctors, Mr. Tyazhelnikov believes.

Co-chairman of the medical workers’ union “Action” Andrei Konoval fears that the records could be accessed in order to compare them with a specific appointment or even a patient: “The records themselves can be stolen, stolen, leaked. There will be an appeal by name and patronymic, it can be compared with medical documentation and biometric data by persons who have access to both.”

Partner at the law firm Comply, Sergei Sayganov, notes that the medical confidentiality regime provides for no access to medical data of third parties, except for medical institutions and the healthcare system.

The likelihood of a violation of this regime depends mainly on who gets access to these records: “If the records remain within the medical organization itself and the inspection bodies, then there can be no talk of any significant violation, this information will duplicate what is recorded doctor in the patient’s card during the appointment.” According to Mr. Sayganov, another problem arises: “Given that such audio recording is not yet provided for by federal law, medical organizations should obtain the consent of employees to record and regulate this process by local acts. Otherwise, permanent recording may be considered a violation of workers’ rights.” The Department of Health objects: the processing of personal data is not carried out, “this is even more specific in the new version of the order”: “The data is anonymized, there is no technical ability to personalize it. Therefore, consent is not needed.”

Co-chairman of the All-Russian Patients’ Union Yuri Zhulev supports the department’s initiative. In his opinion, another tool is emerging that helps improve the level of ethics in communication between doctor and patient and reduce conflict. The amendments regarding the period and mode of storage of records, as well as liability for their leakage, remove, in his opinion, “all questions and concerns.” “We suggested that the department specify the wording to remove public concerns. And now we see that the audio recordings have been depersonalized, unlinked from the doctor and from the medical record, and the storage period has been specified. The audio recording is subject to the legislation on medical confidentiality, and its distribution will be punished accordingly,” says Mr. Zhulev.

The Moscow Department of Health emphasizes that audio monitoring is a tool aimed solely at “improving communication between the doctor and the patient during an appointment, and it will not be used for any other purposes,” and medical confidentiality “will be maintained 100%.”

Natalia Kostarnova